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Neonatal emergencies

Dr. Miada Mahmoud Rady

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Definitions

I. Newborn : A recently born infant, usually during the

first few hours of life.

II. Neonate : Baby during the first 28 days of life.

III. Preterm : less than 37 completed weeks.

IV. Term : 38 to 42 completed weeks.

V. Post-term : more than 42 weeks.

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Transition from fetal to neonatal circulation

With the first breath, circulation changes.

1. Larger amount of blood is sent to the lungs

2. Ductus arteriosus begins to wither and close off

3. Circulation to the lungs increases left atrium

flow, increased pressure causes the foremen

ovale to close and blood circulates normally

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Transition from fetal to neonatal circulation

Respiratory system must suddenly initiate and

maintain oxygen:

– Change from maternal circulation (placenta) to

neonatel circulation.

– Chest expands, fluid is forced from lungs and oxygen

exchange begins.

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• Stimulant for the first breath:

1. First breath triggered by mild hypoxia and hypercapnia

from partial occlusion of the umbilical cord during

delivery.

2. Also Tactile stimulation and cold stress promote early

breathing.

During the first breath , pulmonary vascular

resistance drops .

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Delay in drop pulmonary pressure leads to:

a.Delayed transition

b.Hypoxia

c. Brain injury

d.Death

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Epidemiology of fetal distress• Incidence

– Approximately 6% of deliveries require life support

– Incidence of complications increases as Birth Weight

Decreases

• Morbidity / mortality

– Neonatal mortality risk can be determined based on birth

weight and gestational age

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Risk factorsA. Antepartum factors

1. Multiple gestation

2. Inadequate prenatal care

3. Mother’s age <16 or >35

4. Post-term gestation

5. Drugs / medications

6. Toxemia, hypertension, diabetes

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Risk factorsB. Intrapartum factors

1. Meconium-stained amniotic fluid

2. Rupture of membranes greater than 24 hours prior to delivery

3. Abnormal presentation

4. Prolonged labor or precipitous delivery

5. Prolapsed cord

6. Sever bleeding

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Neonatal resuscitation 1. Initial steps of neonatal resuscitation include:

I. Airway (position and clear)

II. Breathing (stimulate to breathe)

III. Circulation (assess heart rate and oxygenation)

2. Additional resuscitation steps :

• They are used based on need and include →

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1. supplemental oxygen.

2. positive pressure ventilation.

3. Intubation.

4. chest compressions.

5. medications.

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Initial steps of stabilizing a newborn

I. Warming the newborn to prevent hypothermia.

II. Positioning the newborn

III. Clearing the airway if necessary

IV. Drying and stimulating breathing

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I. Warming the newborn to prevent hypothermia:

1. Place on prewarmed towels or blankets and dry.

2. Replace wet towels with dry, prewarmed ones.

3. When resuscitation is complete, place the newborn on

the mother’s chest or abdomen, another heat source, or

under a radiant warmer.

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Positioning the newborn:

1. Position on the back or side with the neck in the sniffing

position.

2. Use a small shoulder roll to keep the head in this position.

Clearing the airway :

1. Use a bulb syringe or suction catheter.

2. Turn the head to the side.

3. Suction the mouth before the nose to prevent aspiration.

4. Return the head to the sniffing position.

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Drying and stimulating breathing

1. Dry the head and body with towels to provide

stimulation.

2. Additional tactile stimulation methods include:

3. Slapping/flicking soles of the feet

4. Rubbing gently on the back or trunk

5. Keep appropriate position of the head throughout

stimulation.

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Basic requirement of neonatal delivery

1. Warm, dry blankets

2. Bulb syringe

3. Two small clamps or ties

4. A pair of clean scissors

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Equipment for Neonatal Resuscitation

1. Manual resuscitator (infant)

2. Masks (2 sizes, term and premature)

3. Dry towels/blankets

4. Suction equipment

5. ET tubes (sizes 2.5, 3.0, 3.5)

6. Laryngoscope and blades (sizes 0, 1)

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APGAR SCORE

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APGAR test

Definition :

1. A quick test performed on a baby at 1 and 5

minutes after birth.

• The 1-minute score determines how well the

baby tolerated the birthing process.

• The 5-minute score determines how well

the baby is doing outside the mother's womb.

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How the test is done?.............................

• You will examine the baby's:

1. Breathing effort

2. Heart rate

3. Muscle tone

4. Reflexes

5. Skin color

Each category is

scored with 0, 1, or

2, depending on the

observed condition

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• This test is done to determine whether a newborn

needs help breathing or is having heart trouble.

Normal Results

1. The APGAR rating is based on a total score of 1 to

10.

2.  The higher the score, the better the baby is doing

after birth.

3. A score of 7, 8, or 9 is normal and is a sign that

the newborn is in good health.

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APGAR score

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A for appearance

1. Appearance (Skin color):

• If the skin color is pale blue, the infant scores 0 for

color.

• If the body is pink and the extremities are blue, the

infant scores 1 for color.

• If the entire body is pink, the infant scores 2 for

color

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2. Pulse (Heart rate) : is evaluated by stethoscope ,this is the most important

assessment:

– If there is no heartbeat, the infant scores 0 for heart rate.

– If heart rate is less than 100 beats per minute, the infant scores

1 for heart rate.

– If heart rate is greater than 100 beats per minute, the infant

scores 2 for heart rate.

P for pulse

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G for grimace

3. Grimace response ( reflex irritability ):

• It is a term describing response to stimulation such as a

mild pinch :

– If there is no reaction, the infant scores 0 for reflex irritability.

– If there is grimacing, the infant scores 1 for reflex irritability.

– If there is grimacing and a cough, sneeze, or vigorous cry, the

infant scores 2 for reflex irritability.

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3. Activity ( Muscle tone):

– If muscles are loose and floppy, the infant scores 0 for

muscle tone.

– If there is some muscle tone, the infant scores 1.

– If there is active motion, the infant scores 2 for muscle

tone.

A for activity

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R for respiration

1. Respiration ( Breathing )effort:

– If the infant is not breathing, the respiratory score

is 0.

– If the respirations are slow or irregular, the infant

scores 1 for respiratory effort.

– If the infant cries well, the respiratory score is 2.

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Neonatal resuscitation algorithm

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Neonatal Resuscitation Guidelines:• Dry the baby with a clean cloth• Check for:

1. Breathing or crying2. Pink central color3. Good tone

• If all present, continue routine care• If baby does not have good respiratory effort, pink central color

AND good tone:1. Position infant in neutral position2. Clear airway3. Stimulate4. Give oxygen if available

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Neonatal Resuscitation Guidelines:• If baby responds to positioning and stimulation by turning pink

and breathing, return to routine care• If baby does not respond to these measures within 30 seconds:

1. Apply mask and ventilation bag to infant2. Give 5 slow breaths

• If baby responds and begins breathing, continue to observe closely, return to giving routine care

• If baby is not breathing after 5 slow breaths:1. Check position of infant2. Continue bag and mask ventilation3. Check to see if chest is rising: if there is no chest movement,

suction airway, reposition infant, then resume bag and mask ventilation

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Neonatal Resuscitation Guidelines:• If not breathing after 30 seconds:

– Check heart rate• If heart rate is > 60 beats per minute:

1. Continue to ventilate at 40 breaths per minute2. Use oxygen to ventilate if available3. Watch for chest rise4. Monitor position of infant5. Stop ventilation every 1-2 mins to see if HR is greater than 60

beats per minute6. Stop compressions if HR is > 100 beats per minute7. Stop ventilations when breathing is > 30 breaths per minute8. Continue oxygen therapy until infant is pink and has good

tone

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Neonatal Resuscitation Guidelines:• If not breathing after 30 seconds:

– Check heart rate• If heart rate is > 60 beats per minute:

1. Continue to ventilate at 40 breaths per minute2. Use oxygen to ventilate if available3. Watch for chest rise4. Monitor position of infant5. Stop ventilation every 1-2 mins to see if HR is greater than 60

beats per minute6. Stop compressions if HR is > 100 beats per minute7. Stop ventilations when breathing is > 30 breaths per minute8. Continue oxygen therapy until infant is pink and has good

tone

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• If heart rate is < 60 beats per minute:

– Continue effective Positive Pressure Ventilation and

begin chest compressions at a rate of 90

compressions/minute

– Continue chest compressions until HR>60 beats per minute

– Continue to ventilate at 40 breaths per minute

– Use oxygen to ventilate if available

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– Watch for chest rise

– Monitor position of infant – should be neutral head position

– Stop ventilation every 1-2 mins to see if HR is greater than 60

beats per minute

– Stop compressions if HR is > 100 beats per minute

– Stop ventilations when breathing is > 30 breaths per minute

– Continue oxygen therapy until infant is pink and has good tone

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Neonatal Resuscitation Guidelines:

• Cessation of resuscitation

– If after 20 minutes the baby is not breathing and there is no

pulse, the recommendation is to stop resuscitation efforts

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Thank you

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Arrival of the newborn

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History taking 1. Woman’s age

2. Length of pregnancy

3. Presence and frequency of contractions

4. Presence or absence of fetal movement

5. Any pregnancy complications

6. If membranes have ruptured ( Timing , color of fluid ).

7. Medications being taken

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Resuscitation oriented history

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If delivered in the ambulance………….

1. Cover the foot of the stretcher with clean, warm

blankets for the initial stabilization.

2. After confirming adequate airway, breathing, and pulse

rate, place the newborn on the mother’s chest.

3. If more extensive resuscitation is necessary, transition

newborn to a second ambulance with a neonatal

transport incubator

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4. Suction the mouth, then the nose with a bulb syringe

once the head is delivered.

5. Keep the newborn at the level of the mother after

delivery, with head slightly lower than the body.

• ►►►If the cord comes out ahead of the newborn, the

blood supply to the fetus may be cut off (prolapsed

cord) , ►►►so relieve pressure on the cord by gently

moving the newborn’s body off the cord and pushing the

cord back.

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6. Do an initial rapid assessment simultaneous with

treatment interventions.

• Note time of delivery.

• Monitor ABCs.

• Assess airway patency, respiratory rate and effort, tone, pulse

rate, and color.

7. Position the newborn in the sniffing position to ensure a

patent airway, clear secretions, and assess the

respiratory effort.

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Opening the Airway

Wrong positioning:

Right positioning

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7. Newborn is at risk for hyperthermia , so ensure

thermoregulation by:

Placing the newborn on prewarmed towels or radiant

warmer

Drying the head and body thoroughly

Discarding wet towels and covering with a dry towel

Covering the head with a cap

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Finally ……………………….

8. All babies are cyanotic right after birth , If the newborn

stays vigorous and begins to turn pink in the first 5

minutes:

Maintain ongoing observation.

Continue thermoregulation with direct skin-to-skin

contact with mother while en route.

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Additional resuscitation steps…..

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Airway management1. Free-flow oxygen:

If a newborn is cyanotic or pale, provide supplemental oxygen ,

until a pulse oximetry reading can give an accurate reading.

Oxygen flow rate should be 5 L/min.

oxygen can initially be delivered through:

1. PPV (first choice unless not indicated)

2. Oxygen mask

3. Oxygen tubing cupped and held close to the newborn’s nose and

mouth.

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1. Oral airways :

• Rarely used on newborns , but it can be life saving in Bilateral

Choanal Atresia .

• Bilateral Choanal Atresia : Bony or membranous obstruction of

the back of the nose.

• Management :

1. Surgical correction is definitive treatment.

2. First aid measure : keeping newborn mouth open either by oral

air way or gloved finger .

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• Other Conditions that may require oral airways:

1. Pierre Robin sequence

2. Macroglossia (large tongue)

3. Craniofacial defects that affect the airway

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Breathing

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If a newborn baby fails to breathe after

bulb suctioning, then Positive Pressure

Ventilation With A Bag-and-mask is

the single most important step in

neonatal resuscitation.

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Bag-mask ventilation• Indicated when a newborn:

1. apneic

2. Has inadequate respiratory effort

3. Has a pulse rate of less than 100 beats/min after:

Airway is cleared of secretions.

Tongue obstruction is relieved.

Newborn is dried and stimulated.

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Signs of respiratory distress suggesting need for bag-mask

ventilation include:

1. Periodic breathing

2. Grunting on expiration

3. Nasal flaring

4. Intercostal retractions

The correct ventilation time (40 to 60 breaths/min) is important

because a higher rate can cause:

1. Hypocapnia

2. Air trapping

3. Pneumothorax

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• Continue PPV as long as the pulse rate is less than 100 beats/min

or the respiratory effort is ineffective.

• If more than 1 minute of PPV is needed, hook the system to a

pressure manometer.

• Causes of ineffective bag-mask ventilation:

I. Inadequate mask seal on the face

II. Incorrect head position

III. Copious secretions

IV. Pneumothorax

V. Equipment malfunction

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• Gently pull infant’s jaw forward to mask

• Use a “C-grip” to hold mask to infant’s face, using the

3rd finger to hold jaw up to mask

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Correct positioning : Watching for chest-rise- if chest is rising

and falling you are performing adequate ventilation

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Intubation• Indications :

1. Meconium aspiration .

2. Diaphragmatic hernia .

3. No response to bag-mask ventilation and chest compressions,

necessitating ET administration of epinephrine

4. Prolonged PPV needed.

5. Craniofacial defects impede an adequate airway.

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• Complications of ET tube placement include:

1. Oropharyngeal or tracheal perforation

2. Esophageal intubation with subsequent persistent

hypoxia

3. Right main stem intubation

• Risks can be minimized by:

1. Ensuring optimal placement of laryngoscope blade

2. Noting how far the ET tube is advanced

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Circulation

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Chest compression

• Chest compression is indicated if pulse rate remains

at less than 60 beats/min despite of :

1. Positioning.

2. Clearing airway.

3. Drying and stimulations.

4. 30 seconds of effective PPV.

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Criteria of chest compression in newborn

1. Two people are needed for effective chest compressions while

ventilating.

2. Two different techniques:

• Thumb technique . (preferred one)

• Two finger technique .

3. The compression depth is one third of the anteroposterior

diameter of the chest.

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4. Chest compressions and artificial ventilation should not be

delivered simultaneously.

• { Coordinate 90 compressions and 30 breaths/min , equaling

120 events per minute (1/2 second each) }.

5. Pulse rate should not be assessed for at least 45 to 60 seconds

after ventilation and chest compressions are established.

• { Interruption of chest compressions to assess the pulse may

decrease perfusion of coronary arteries }.

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Stopping chest compression

1. If pulse rate is above 60 beats/min:

• Chest compressions can be stopped.

• Effective ventilation should continue at 40 to 60

breaths/min.

• Recheck pulse rate after 30 seconds.

2. If the pulse rate goes above 100 beats/min:

• gradually slow the rate and decrease PPV pressure.

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Hypovolemia In Newborn

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Etiology

1. Placenta abruption

2. Twin-to-twin transfusion

3. Placenta previa

4. Septic shock

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Signs

1. Pallor

2. Persistently low pulse rate

3. Weak pulses

4. No improvement in circulatory status after adequate

resuscitation efforts.

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Treatment 1. Place a low umbilical vein line in a newborn.

2. If more than a few days old, place a peripheral IV or IO line.

3. Fluid bolus in a newborn is 10 mL/kg given IV every 5 to 10

minutes of:

• Saline

• Lactated Ringer’s

• O Rh-negative blood

4. Multiple boluses may be given if needed.

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